Intraocular hemorrhage: Difference between revisions

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Latest revision as of 22:25, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Luke Rusowicz-Orazem, B.S.

Ocular Anatomy

The volume of the vitreous in the adult is about 4 cc or 80% of the volume of the eye's globe. Water makes up 99% of the vitreous content. The remaining 1% mostly is composed of collagen and hyaluronic acid which although clear, causes the vitreous to be gelatinous.

The vitreous is attached to the retina in three locations. The vitreous base refers to a 4 mm circular band where the vitreous body attaches to the anterior retina (ora serrata). This is the strongest of the three attachments. The vitreous also attaches in a circular zone around the optic nerve head. This is the second strongest attachment of the vitreous. This attachment becomes progressively weaker with advanced age, and it is this attachment that may become separated in posterior vitreous detachment.

The vitreous is itself avascular and therefore the blood in vitreous hemorrhage comes from organs outside the vitreous. When hemorrhage occurs into the vitreous, it accumulates in potential spaces within and around the vitreous body. These potential spaces for blood to accumulate include the following:

The retrolental space of Erggelet
The canal of Petit
The Cloquet canal
The bursa premacularis
The canal of Hannover (between the orbiculoanterocapsular and posterocapsular portions of the zonular fibers)

The borders of the vitreous body are as follows:

Posterior: The internal limiting membrane of the retina

Anterior: The nonpigmented epithelium of the ciliary body, and anteriorly by the lens zonular fibers and posterior lens capsule.

Pathophysiology

The two most common overarching pathophysiologic mechanisms of vitreous hemorrhage involve hemorrhage into the vitreous from a diseased retina or trauma. Specific pathophysiologic mechanisms are discussed below:

Extraocular Causes of Vitreal Hemorrhage

Diabetes and sickle cell disease are obvious extraocular diseases that are associated with retinopathy. Retinopathy is characterized by neovascular vessels, fragile vessels, occluded vessels and ischemic vessels, all of which increase the risk of vitreous hemorrhage. The disorders are associated with retinal ischemia which in turn causes the release of angiogenic growth factors including vascular endothelial growth factor (VEGF), basic fibroblast growth factors (bFGF), and insulin-like growth factor (IGF).

Trauma is another major pathophysiologic mechanism of intraocular hemorrhage.

Conditions that may increase the risk of vitreal hemorrhage also include coagulation disorders (e.g. leukemia and thrombocytopenia). While coagulation disorders may not themselves be primarily associated with bleeding, in the presence of trauma or retinopathy they may secondarily increase the risk of bleeding. Autoimmune / collagen vascular disorders such as Behcets disease and sarcoid have also been associated with an increased risk of intraocular hemorrhage. Thus a careful history should be obtained regarding all these systemic / extraocular causes.

Subretinal Bleeeding with Breakthrough Bleeding into the Vitreous

Other less common pathological mechanisms of vitreous hemorrhage include subretinal bleeding with secondary extension into the vitreous cavity.

Age-related macular degeneration and choroidal melanoma are the two leading causes of vitreous hemorrhage secondary to breakthrough bleeding. Terson syndrome is subarachnoid hemorrhage associated with vitreous bleeding caused by rupture of retinal venules and/or capillaries as a result of a sudden increase in intracranial pressure (which is transmitted to the retinal vasculature via the optic nerve).

Subarachnoid Hemorrhage and Associated Intraocular Hemorhhage

Approximately one of three patients with subarachnoid hemorrhage will sustain an intraocular hemorrhage, and approximately 6% of patients have vitreous hemorrhage.

Terson Syndrome

In this condition, the branches of the central retinal vein or the central retinal vein itself are generally the source of intraocular bleeding. This syndrome occurs predominantly in patients aged 30 to 50 years.

Causes

Common Causes

Proliferative diabetic retinopathy
Posterior vitreous detachment
Trauma (blunt or penetrating, including shaken baby syndrome/child abuse)
Retinal tear
Central retinal vein occlusion
Hypertensive retinopathy
Subarachnoid hemorrhage (Terson syndrome)
Avulsed retinal vessels
Age-related macular degeneration
Radiation retinopathy
Macroaneurysms

Causes by Organ System

Cardiovascular	Avulsed retinal vessels, Branch retinal artery occlusion, Central retinal artery occlusion, Central retinal vein occlusion, Disseminated intravascular coagulation, Dominant exudative vitreoretinopathy, Eales disease , Hypertensive retinopathy, Macroaneurysms, Neovascularization, Ocular ischemic syndrome, Persistent hyaloid artery, Retinal vasculitis, Thrombolysis, Vascular loop venous stasis retinopathy
Chemical/Poisoning	Talc retinopathy
Dental	No underlying causes
Dermatologic	Behçet disease, Cavernous hemangioma , Melanocytoma
Drug Side Effect	Anticoagulants, Antiphospholipid antibodies, Drug side effect, Ocriplasmin
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	High altitude
Gastroenterologic	Astrocytic hamartoma
Genetic	Incontinentia pigmenti, Norrie disease, Sarcoid posterior uveitis, Von willebrand syndrome
Hematologic	Anticoagulants, Antiphospholipid antibodies, Coats disease , Congenital prepapillary, Hemophilia, Hyperviscosity syndrome, Idiopathic thrombocytopenia purpura, Leukemia, Proliferative sickle cell retinopathy, Retinal angiomatosis, Retinal macroaneurysm rupture, Subarachnoid hemorrhage , Thrombocytopenia, Thrombotic thrombocytopenic purpura, Von willebrand syndrome
Iatrogenic	Intraocular lens implantation , Intraocular lens removal, Intruding scleral buckle, Radiation retinopathy, Retinal laser photocoagulation, Trabeculectomy
Infectious Disease	Presumed ocular histoplasmosis syndrome, Syphilitic retinitis, Toxocara, Uveitis
Musculoskeletal/Orthopedic	Dermatomyositis
Neurologic	Cavernous hemangioma , Macroaneurysms, Subarachnoid hemorrhage , Thrombolysis
Nutritional/Metabolic	Proliferative diabetic retinopathy, Protein c deficiency
Obstetric/Gynecologic	No underlying causes
Oncologic	Astrocytic hamartoma , Leukemia, Malignant choroidal melanoma, Melanocytoma , Retinoblastoma, Tumors
Ophthalmologic	Age-related macular degeneration, Avulsed retinal vessels, Branch retinal artery occlusion, Central retinal artery occlusion, Central retinal vein occlusion, Coats disease , Congenital prepapillary, Dominant exudative vitreoretinopathy, Eales disease , Globe perforation, Hypertensive retinopathy, Intraocular lens implantation , Intraocular lens removal, Intruding scleral buckle, Malignant choroidal melanoma, Norrie disease, Ocular ischemic syndrome, Orbital fracture, Persistent hyaloid artery, Pigmentosa valsalva retinopathy, Posterior vitreous detachment, Presumed ocular histoplasmosis syndrome, Proliferative sickle cell retinopathy, Proliferative diabetic retinopathy, Radiation retinopathy, Retinal angiomatosis, Retinal detachment, Retinal macroaneurysm rupture, Retinal tear, Retinal laser photocoagulation, Retinal vasculitis, Retinitis, Retinoblastoma, Retinopathy of prematurity, Sarcoid posterior uveitis, Talc retinopathy, Trabeculectomy
Overdose/Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal/Electrolyte	No underlying causes
Rheumatology/Immunology/Allergy	Behçet disease, Dermatomyositis, Inflammation, Systemic lupus erythematosus
Sexual	Syphilitic retinitis
Trauma	Globe perforation, Orbital fracture, Retinal detachment, Retinal tear, Trauma
Urologic	No underlying causes
Miscellaneous	No underlying causes

Causes in Alphabetical Order

External Links

A British Medical Journal report into retinal haemorrhaging and strokes in children

References

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Template:WikiDoc Sources

@@ Line 6: / Line 6: @@
 }}
 {{SI}}
-{{CMG}}
+{{CMG}}{{AE}} {{LRO}}
 ==Ocular Anatomy==
 The volume of the vitreous in the adult is about 4 cc or 80% of the volume of the eye's globe.  Water makes up 99% of the vitreous content. The remaining 1% mostly is composed of collagen and hyaluronic acid which although clear, causes the vitreous to be gelatinous.
@@ Line 46: / Line 45: @@
 ===Terson Syndrome===
-In this condition, the branches of the [[central retinal vein]] or the central retinal vein itself are generally the source of intraocular bleeding.  This syndrome occurs predominantly patients aged 30 to 50 years.
+In this condition, the branches of the [[central retinal vein]] or the central retinal vein itself are generally the source of intraocular bleeding.  This syndrome occurs predominantly in patients aged 30 to 50 years.
-==Differential Diagnosis of Causes of Intraocular Hemorrhage==
-In general, vitreous hemorrhage results from tears of the retina or neovascularization of the retina
-'''Common causes in descending order of frequency'''
-Proliferative [[diabetic retinopathy]]
-[[Posterior vitreous detachment]]
-[[Trauma]] (blunt or penetrating, including [[shaken baby syndrome]]/child abuse)
-[[Retinal tear]]
-[[Central retinal vein]] occlusion
-[[Hypertensive retinopathy]]
-[[Subarachnoid hemorrhage]] ([[Terson syndrome]])
-Avulsed retinal vessels
-Age-related [[macular degeneration]]
-[[Radiation]] retinopathy
-Macro[[aneurysm]]s
-'''Others rare causes of vitreous hemorrhage include the following:'''
-===Complications of surgical procedures===
-Retinal [[laser photocoagulation]]
-Intruding (scleral erosion) [[scleral buckle]]
-[[Trabeculectomy]]
-Globe perforation during retrobulbar or peribulbar surgery/anesthesia
-Intraocular lens implantation or removal
-Neovascularization from [[cataract]] wound
-===Tumors===
-Malignant choroidal [[melanoma]]
-[[Melanocytoma]] of optic nerve disc
-Astrocytic hamartoma of the retina
-[[Retinoblastoma]]
-[[Cavernous hemangioma]] of optic nerve disc
-===Vascular/neovascular===
-[[Coats disease]] / retinal telangiectasia
-[[Retinopathy of prematurity]] (ROP)
-Ocular ischemic syndrome
-Branch retinal artery occlusion
-[[Central retinal artery]] occlusion
-Retinal angiomatosis
-Retinal [[vasculitis]]
-[[Hyperviscosity syndrome]]
-[[Sarcoid]] posterior [[uveitis]]
-Persistent hyaloid artery
-Congenital prepapillary
-Vascular loop venous stasis retinopathy
-Dominant (familial) exudative vitreoretinopathy
-Incontinentia pigmenti
-[[Norrie disease]]
-===Inflammation===
-[[Behçet disease]]
-Presumed ocular [[histoplasmosis]] syndrome
-[[Eales disease]] (also known as also known as [[angiopathia retinae juvenilis]], [[periphlebitis retinae]], [[primary perivasculitis of the retina]])
-[[Uveitis]] (including pars planitis)
-[[Syphilitic]] retinitis
-[[Dermatomyositis]]
-[[Systemic lupus erythematosus]] ([[SLE]])
-[[Toxocara]]
-===Hematologic disorders===
-[[Thrombocytopenia]]
-[[Idiopathic thrombocytopenia purpura]]
-[[Thrombotic thrombocytopenic purpura]]
+==Causes==
+===Common Causes===
+*Proliferative [[diabetic retinopathy]]
+*[[Posterior vitreous detachment]]
+*[[Trauma]] (blunt or penetrating, including [[shaken baby syndrome]]/child abuse)
+*[[Retinal tear]]
+*[[Central retinal vein]] occlusion
+*[[Hypertensive retinopathy]]
+*[[Subarachnoid hemorrhage]] ([[Terson syndrome]])
+*Avulsed retinal vessels
+*Age-related [[macular degeneration]]
+*[[Radiation]] retinopathy
+*Macro[[aneurysm]]s
-[[Leukemia]]
+===Causes by Organ System===
+{|style="width:80%; height:100px" border="1"
+|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" |'''Cardiovascular'''
+|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Avulsed retinal vessels]],  [[Branch retinal artery occlusion]],  [[Central retinal artery occlusion]],  [[Central retinal vein occlusion]],  [[Disseminated intravascular coagulation]],  [[Dominant exudative vitreoretinopathy]],  [[Eales disease ]],  [[Hypertensive retinopathy]],  [[Macroaneurysms]],  [[Neovascularization]],  [[Ocular ischemic syndrome]],  [[Persistent hyaloid artery]],  [[Retinal vasculitis]],  [[Thrombolysis]],  [[Vascular loop venous stasis retinopathy]]
+|-
+|bgcolor="LightSteelBlue"| '''Chemical/Poisoning'''
+|bgcolor="Beige"| [[Talc retinopathy]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Dental'''
+|bgcolor="Beige"| No underlying causes
+|-
+|-bgcolor="LightSteelBlue"
+| '''Dermatologic'''
+|bgcolor="Beige"| [[Behçet disease]], [[Cavernous hemangioma ]], [[Melanocytoma ]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Drug Side Effect'''
+|bgcolor="Beige"| [[Anticoagulants]],  [[Antiphospholipid antibodies]],  [[Drug side effect]],  [[Ocriplasmin]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Ear Nose Throat'''
+|bgcolor="Beige"| No underlying causes
+|-
+|-bgcolor="LightSteelBlue"
+| '''Endocrine'''
+|bgcolor="Beige"| No underlying causes
+|-
+|-bgcolor="LightSteelBlue"
+| '''Environmental'''
+|bgcolor="Beige"| [[High altitude]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Gastroenterologic'''
+|bgcolor="Beige"| [[Astrocytic hamartoma]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Genetic'''
+|bgcolor="Beige"| [[Incontinentia pigmenti]],  [[Norrie disease]],  [[Sarcoid posterior uveitis]],  [[Von willebrand syndrome]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Hematologic'''
+|bgcolor="Beige"| [[Anticoagulants]],  [[Antiphospholipid antibodies]],  [[Coats disease ]],  [[Congenital prepapillary]],  [[Hemophilia]],  [[Hyperviscosity syndrome]],  [[Idiopathic thrombocytopenia purpura]],  [[Leukemia]],  [[Proliferative sickle cell retinopathy]],  [[Retinal angiomatosis]],  [[Retinal macroaneurysm rupture]],  [[Subarachnoid hemorrhage ]],  [[Thrombocytopenia]],  [[Thrombotic thrombocytopenic purpura]],  [[Von willebrand syndrome]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Iatrogenic'''
+|bgcolor="Beige"| [[Intraocular lens implantation ]],  [[Intraocular lens removal]],  [[Intruding scleral buckle]],  [[Radiation retinopathy]],  [[Retinal laser photocoagulation]],  [[Trabeculectomy]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Infectious Disease'''
+|bgcolor="Beige"| [[Presumed ocular histoplasmosis syndrome]],  [[Syphilitic retinitis]],  [[Toxocara]],  [[Uveitis ]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Musculoskeletal/Orthopedic'''
+|bgcolor="Beige"| [[Dermatomyositis]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Neurologic'''
+|bgcolor="Beige"| [[Cavernous hemangioma ]],  [[Macroaneurysms]],  [[Subarachnoid hemorrhage ]],  [[Thrombolysis]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Nutritional/Metabolic'''
+|bgcolor="Beige"| [[Proliferative diabetic retinopathy]],  [[Protein c deficiency]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Obstetric/Gynecologic'''
+|bgcolor="Beige"| No underlying causes
+|-
+|-bgcolor="LightSteelBlue"
+| '''Oncologic'''
+|bgcolor="Beige"| [[Astrocytic hamartoma ]],  [[Leukemia]],  [[Malignant choroidal melanoma]],  [[Melanocytoma ]],  [[Retinoblastoma]],  [[Tumors]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Ophthalmologic'''
+|bgcolor="Beige"| [[Age-related macular degeneration]],  [[Avulsed retinal vessels]],  [[Branch retinal artery occlusion]],  [[Central retinal artery occlusion]],  [[Central retinal vein occlusion]],  [[Coats disease ]],  [[Congenital prepapillary]],  [[Dominant exudative vitreoretinopathy]],  [[Eales disease ]],  [[Globe perforation]],  [[Hypertensive retinopathy]],  [[Intraocular lens implantation ]],  [[Intraocular lens removal]],  [[Intruding scleral buckle]],  [[Malignant choroidal melanoma]],  [[Norrie disease]],  [[Ocular ischemic syndrome]],  [[Orbital fracture]],  [[Persistent hyaloid artery]],  [[Pigmentosa valsalva retinopathy]],  [[Posterior vitreous detachment]],  [[Presumed ocular histoplasmosis syndrome]],  [[Proliferative sickle cell retinopathy]],  [[Proliferative diabetic retinopathy]],  [[Radiation retinopathy]],  [[Retinal angiomatosis]],  [[Retinal detachment]],  [[Retinal macroaneurysm rupture]],  [[Retinal tear]],  [[Retinal laser photocoagulation]],  [[Retinal vasculitis]],  [[Retinitis]],  [[Retinoblastoma]],  [[Retinopathy of prematurity]],  [[Sarcoid posterior uveitis]],  [[Talc retinopathy]],  [[Trabeculectomy]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Overdose/Toxicity'''
+|bgcolor="Beige"| No underlying causes
+|-
+|-bgcolor="LightSteelBlue"
+| '''Psychiatric'''
+|bgcolor="Beige"| No underlying causes
+|-
+|-bgcolor="LightSteelBlue"
+| '''Pulmonary'''
+|bgcolor="Beige"| No underlying causes
+|-
+|-bgcolor="LightSteelBlue"
+| '''Renal/Electrolyte'''
+|bgcolor="Beige"| No underlying causes
+|-
+|-bgcolor="LightSteelBlue"
+| '''Rheumatology/Immunology/Allergy'''
+|bgcolor="Beige"| [[Behçet disease]],  [[Dermatomyositis]],  [[Inflammation]],  [[Systemic lupus erythematosus ]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Sexual'''
+|bgcolor="Beige"| [[Syphilitic retinitis]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Trauma'''
+|bgcolor="Beige"| [[Globe perforation]],  [[Orbital fracture]],  [[Retinal detachment]],  [[Retinal tear]],  [[Trauma]]
+|-
+|-bgcolor="LightSteelBlue"
+| '''Urologic'''
+|bgcolor="Beige"| No underlying causes
+|-
+|-bgcolor="LightSteelBlue"
+| '''Miscellaneous'''
+|bgcolor="Beige"| No underlying causes
+|-
+|}
-[[Hemophilia]]
+===Causes in Alphabetical Order===
+{{columns-list|
-[[Disseminated intravascular coagulation]]
+*[[Age-related macular degeneration]]
+*[[Anticoagulants]]
-[[Protein C deficiency]]
+*[[Antiphospholipid antibodies]]
+*[[Astrocytic hamartoma ]]
-[[Antiphospholipid antibodies]]
+*[[Avulsed retinal vessels]]
+*[[Behçet disease]]
-Von Willebrand syndrome
+*[[Branch retinal artery occlusion]]
+*[[Cavernous hemangioma ]]
-===Miscellaneous causes===
+*[[Central retinal artery occlusion]]
+*[[Central retinal vein occlusion]]
-*Talc retinopathy
+*[[Coats disease ]]
+*[[Congenital prepapillary]]
+*[[Dermatomyositis]]
+*[[Disseminated intravascular coagulation]]
+*[[Dominant exudative vitreoretinopathy]]
+*[[Drug side effect]]
+*[[Eales disease ]]
+*[[Globe perforation]]
+*[[Hemophilia]]
+*[[High altitude]]
+*[[Hypertensive retinopathy]]
+*[[Hyperviscosity syndrome]]
+*[[Idiopathic thrombocytopenia purpura]]
+*[[Incontinentia pigmenti]]
+*[[Inflammation]]
+*[[Intraocular lens implantation ]]
+*[[Intraocular lens removal]]
+*[[Intruding scleral buckle]]
+*[[Leukemia]]
+*[[Macroaneurysms]]
+*[[Malignant choroidal melanoma]]
+*[[Melanocytoma ]]
+*[[Neovascularization]]
+*[[Norrie disease]]
+*[[Ocriplasmin]]
+*[[Ocular ischemic syndrome]]
+*[[Orbital fracture]]
+*[[Persistent hyaloid artery]]
+*[[Pigmentosa valsalva retinopathy]]
+*[[Posterior vitreous detachment]]
+*[[Presumed ocular histoplasmosis syndrome]]
+*[[Proliferative sickle cell retinopathy]]
+*[[Proliferative diabetic retinopathy]]
+*[[Protein c deficiency]]
+*[[Radiation retinopathy]]
+*[[Retinal angiomatosis]]
+*[[Retinal detachment]]
+*[[Retinal macroaneurysm rupture]]
+*[[Retinal tear]]
+*[[Retinal laser photocoagulation]]
+*[[Retinal vasculitis]]
 *[[Retinitis]]
-*Pigmentosa Valsalva retinopathy
+*[[Retinoblastoma]]
+*[[Retinopathy of prematurity]]
+*[[Sarcoid posterior uveitis]]
+*[[Subarachnoid hemorrhage ]]
+*[[Syphilitic retinitis]]
+*[[Systemic lupus erythematosus ]]
+*[[Talc retinopathy]]
+*[[Thrombocytopenia]]
+*[[Thrombolysis]]
+*[[Thrombotic thrombocytopenic purpura]]
+*[[Toxocara]]
+*[[Trabeculectomy]]
+*[[Trauma ]]
+*[[Tumors]]
+*[[Uveitis ]]
+*[[Vascular loop venous stasis retinopathy]]
+*[[Von willebrand syndrome]]
+}}
-==External links==
+==External Links==
 *[http://adc.bmjjournals.com/cgi/content/full/84/3/263 A British Medical Journal report into retinal haemorrhaging and strokes in children]
+==References==
+{{Reflist|2}}
 {{Eye}}
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 {{Eye pathology}}
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-[[category:Primary care]]
 [[Category:Ophthalmology]]
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+[[Category:Medical signs]]
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